As the swine flu pandemic descends upon the province of Ontario, officials and health practitioners are scrambling to vaccinate and advertise prevention strategies. Flu pandemics appear to be increasing in frequency and the more information that is available, the better. However, I believe there are a few structural changes that need to be made that greatly affect human behaviour and, consequently, the spreading of contagious disease. I make these recommendations not as an epidemiologist, or an architect or even a social anthropologist. I am a legal anthropologist. I am interested in how people react to new policies, how they understand and navigate contracts and how they respond to new legislated forms of control and power.
Since the bubonic plague, public health has been a justification to exert social control and invasive yet performative surveillance methods (Hörnqvist 2004; Elden 2003). Public health is a utilitarian approach to reconfiguring social bonds: it undermines the individualist bases of risk and harm that underpin western society by instilling peer pressure or a sense of responsibility to one's larger community. It justifies, to a certain degree, compromising personal liberties to protect the whole: we see this in campaigns encouraging hand washing, condom usage, compulsory vaccinations, regular STD testing. These are not bad things - merely behaviour modifications that result in better quality of life and lower mortality rates. In the age of large scale rapid migration in small confined spaces, like airplanes, it is time to think beyond just the development of chemicals and products and examine how germs and the people that carry them interact in space.
From the grocery store, to the lobby of the building I work in, to every bathroom I visit, there are signs posted about proper hand washing. This is good, but it is not the whole story. Entire departments are drawing up Swine Flu policy strategies about how to handle absenteeism. How many of them are changing the taps in the washroom to motion censors to avoid people touching them with clean or dirty hands? Anything that requires a switch should be changed to motion-detection systems to avoid hand-germ-surface contact: lights, doors. What good is it to wash one's hands, if one still has to touch the swinging door handle? I recommend replacing doors with open, maze-like entrances that are still private but avoid hand-germ-surface contact that is easily spread. And what about doors to cars, steering wheels and homes? We need to innovate new solutions that is not only about changing human behaviour, but minimizing its impact. This image, from
Information is Beautiful blog is an effective visual tool for understanding disease control. This shows the fatality rate associated with infectious disease and the maximum survival rates outside of the body (how long they can be infectious). As you can see, swine flu is low on the scale. If I understand this correctly, this means that there are few fatalities and that the disease has a short span of survival outside of the body.
I mentioned earlier that hand sanitizer is proliferating everywhere I go. Most people don't know how to use it. Again, here we see the asymmetrical distribution of information: we are told hand sanitizer that is alcohol based can protect us by killing germs on our hands, but we are not instructed as to how or why it works. When using hand sanitizer, the rubbing action loosens bacteria on our fingers. Allowing the alcohol to evaporate is what kills the bacteria, though, so taking the time to allow your hands to dry is the only way to kill the bacteria properly. We are also told that hand washing will kill bacteria and to avoid anti-bacterial soaps because of adaptive capabilities of bacteria. We are not told that we need to wash our hands in running water with regular soap for at least 30 seconds and to rub our hands vigorously to wash bacteria and dirt out of wrinkles, nooks, or folds - or the worst source - under our nails. Knowledge to change behaviour is only effective if it is complete. It is not enough to tell people to use hand sanitizer or wash their hands.
Voice-over technology has also advanced rapidly and should be considered a major ally in combating the spread of germs in the workplace especially. Assigning individual, unshared, headsets and having to speak, rather than type, at computers would also minimize hand-germ-surface contact. I share a keyboard at work presently because I work shifts. Voice-over technology would be a great way to protect myself and my colleagues from spreading disease.
Air quality and air transfer is another area that needs addressing. I read an article a few years ago that said air quality has deteriorated on airplanes since smoking was prohibited (for an example and larger discussion, see Hocking and Foster (2004)). I get sick every time I fly. The lack of sleep, confined space, the high passenger-bathroom ratio and lack of fresh air are definitely contributing factors that facilitate airborne germs. Removing carpet on airplanes and having pressurized doors on bathrooms would be a good way of minimizing bacteria growth and transfer. We also hear that hospitals are full of air borne or surface-borne bacteria. I haven't found any information about changes to hospital ventilation architecture or even altogether redesigning first response delivery (people who enter clinics or emergency rooms with virus symptoms) sharing the same building as women giving birth or people having heart transplants. Part of fixing the health care system is addressing how architecture organizes mechanisms of triage in order to prevent vulnerable patients and care-workers from infection.
Social pressure, as I mentioned before, makes public health work effectively. People are full of advice and admonishments, and while they may not like being on the receiving end, they certainly don't hesitate to pass it on. How many of us haven't glared at the person who didn't wash their hands when they left the bathroom? We need people to be better informed about which germs spread which way in order to better protect themselves and minimize the spread of disease which takes a toll on the health care system. Part of this is changing popular perceptions about what is acceptable behaviour. My parents used to scold my brother and me if we coughed into our shirt. Now, this is the practice health practitioners are recommending to stem the spread of the flu, rather than coughing into one's hands. We are also a culture that is used to shaking hands or kissing to greet each other. These are socially difficult or awkward behaviours to change or relinquish, but it is much appreciated when I hear someone decline a physical greeting due to illness. The more we take responsibility for ourselves and our behaviour, the better off everyone will be.
Lastly, we need to reassess our economies of risk as well as how personal risk affects our economy. What I mean by this is that people weigh their choices. Risk compensation is one problem when we are talking about health care and infectious disease: people will engage in more risky behaviour if they perceive they have taken "adequate" precautions. If people think hand sanitizer is more effective, they may be more likely to not wash their hands. If these "adequate" precautions are based on misinformation, then we have people taking higher risks with little or no real precautions, which can definitely lead to widespread infection.
How does the flu pandemic affect our economy? This is an easy question to answer: it comes down to the numbers.
The Economist (30 April 2009) cites costs to the Mexican economy at $55 billion a day because of cancelled schools, sporting events and decreased consumer sales. According to research by the WHO in 1999, a pandemic affecting 15-35% of the population would cost $71 billion and $166 billion. In 2006,
Warwick McKibbin and Alexandra Sidorenko found in a study for the Lowy Institute for International Policy in Sydney that even a mild pandemic could shave 0.8% off world GDP (The Economist , 30 April 2009). This is a lot for an already faltering global economy. If we compare this to the costs of vaccines, resources (like body bags, hand sanitizer, coffins), we need to realize that encouraging people to take a few days off work will be better in the long run because they will not spread the flu. In order to do so, we need better compensation packages for people who work, especially in jobs where there are no benefits available. I suggest a tax rebate for businesses that continue to pay their workers when they are off sick due during an officially recognized pandemic. The system goes into effect from the day the public officer of health issues advisories. Short term costs of paying people will mean overall long term productivity. People need to stay home and rest, for the sake of public health and a recovering economy. Earlier, I made recommendations about changing the architecture and tools in a workspace. This sounds expensive. The fact is that it will save money in the long run because it will minimize the spread of disease.
Managing the flu pandemic is difficult and expensive. There are some costs that cost more in the short run, but deliver stability and growth in the long run. These are the changes we need invest in, and they can only be done with complete knowledge and a reconfiguring of how germs and people interact in space.
References:
Magnus Hörnqvist (2004). "The birth of public order policy." Race & Class. 46(1). pp. 30-52.
Stuart Elden (2003). "Plague, Panopticon & Police." Surveillance & Society. 1(3). pp. 240-253.
Martin B. Hocking, Diana Hocking (eds). Air Quality in Airplane Cabins and Similar Enclosed Spaces. Berlin: Springer, 2005.
Martin B. Hocking and Harold D. Foster. (2004). "Common cold transmission in commercial aircraft: Industry and passenger implications. " Journal of Environmental Health Research. 3(1).
Further Reading about Medical Anthropology:
Didier Fassin. (2001). "Quand le corps fait loi: la raison humanitaire dans les procédures de régularisation des étrangers." Sciences sociales et sante. 19(4).
JP Dozon et Didier Fassin. Critique de la sante publique: une approche anthropologique. Balland, 2001.
Didier Fassin. (2005) "Compassion and Repression: The moral economy of immigration policies in France." Cultural Anthropology. pp. 362-387.
Miriam Ticktin. (Feb. 2006). "Where ethics and politics meet: The violence of humanitarianism in France." American Ethnologist in France. 33(1). pp. 33-49.
Margaret Lock and Nancy Scheper-Hughes, (1996). "A Critical-Interpretive Approach in Medical Anthropology: Rituals and Routines of Discipline and Dissent." in C.F. Sargent and T.M. Johnson (Ed.), Medical Anthropology Contemporary Theory and Method: pp. 41-70. (Connecticut: Greenwood Publishing Group, Inc.), 1996.
Image: colorized negative stained transmission electron micrograph (TEM) depicted some of the ultrastructural morphology of the A/CA/4/09 swine flu virus, Photo Credit: C.S. Goldsmith and A. Balish, CDC. Source:
via Wikimedia Commons, images, "flu virus." (Accessed 27Sept09)
